Healthcare Provider Details

I. General information

NPI: 1982156014
Provider Name (Legal Business Name): ALEXANDRA WATKINS LAC, MSTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4447 N HAMLIN AVE #3
CHICAGO IL
60625-5940
US

IV. Provider business mailing address

4447 N HAMLIN AVE #3
CHICAGO IL
60625-5940
US

V. Phone/Fax

Practice location:
  • Phone: 773-628-3622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number189.001185
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: